Medical Declaration

Scuba diving is an exciting and demanding activity. To scuba dive safely, you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem, or who is under the influence of alcohol or drugs, should not dive. If taking medication, consult your doctor before taking part in this program. The purpose of this Medical Declaration is to find out if you should be examined by a physician before participating in recreational diving. A positive response to a question does not necessarily disqualify you from diving. A positive response means there is a pre-existing condition that may affect your safety while diving and you must seek the advice of a physician. Please answer the following questions on your past and present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. If you do tick yes to any of the below questions Click Here to download an RSTC Medical Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to a physician.

Please tick to answer YES to any of the following questions:	Do you currently have an ear infection? Do you have a history of ear disease hearing loss or problems with balance? Do you have a history of ear or sinus surgery? Are you currently suffering from a cold congestion sinusitis or bronchitis? Do you have a history of respiratory problems severe attacks of hayfever or allergies or lung disease? Have you had a collapsed lung (pneumothorax) or history of chest surgery? Do you have active asthma or history of emphysema or tuberculosis? Are you currently taking medication (except oral contraceptives)? Do you have behavioural health mental or psychological problems or a nervous system disorder? Are you or could you be pregnant? Do you have a history of colostomy? Do you have a history of heart disease or heart attack heart surgery or blood vessel surgery? Do you have a history of high blood pressure angina or take medication to control blood pressure? Are you over 45 and have a family history of heart attack or stroke? Do you have a history of bleeding or other blood disorders? Do you have a history of diabetes? Do you have a history of seizures blackouts or fainting convulsions or epilepsy or take medications to prevent them?
First Name: *
Last Name: *


*	I Agree that i have answered all of the above questions honestly
Phone: *
If you are part of a group what is the name of the group?: